European Journal of Pediatrics

, Volume 178, Issue 4, pp 587–591 | Cite as

Use of ketamine by paediatricians in Italian paediatric emergency departments: a missed opportunity?

  • Alberto Di Mascio
  • Benedetta BossiniEmail author
  • Egidio Barbi
  • Franca Benini
  • Giorgio Cozzi
Short Communication


Procedural sedation and analgesia with ketamine are part of daily practice for children undergoing painful procedures in the paediatric emergency department (ED) of North America. A massive number of studies demonstrate ketamine’s safety and efficacy in the hands of trained ED paediatricians, with few severe adverse events (SAEs) recorded. Since there are no data on ketamine’s usage in Italian paediatric EDs, we created a survey to examine procedural sedation with ketamine in the EDs of the Italian PIPER (Pain in Paediatric Emergency Room) group, which includes 36 paediatric EDs providing 1.4 million paediatric visits each year. Results were reviewed using frequencies to describe responses. Thirty-two out of 36 centres replied to the questionnaire. In 6 (19%) out of 32 centres, ketamine is not used at all in the paediatric ED. In 6 centres (23%) of 26 which use ketamine, this drug is autonomously administered by the emergency paediatrician, whereas in 20 (77%) of them it is exclusively managed by the anaesthesiologist on call.

Conclusion: ketamine is autonomously administered only by a small percentage of Italian emergency paediatricians. There is an increasing need for implementation of procedural sedation training and use of ketamine in the everyday practice outside the operating room in paediatric EDs.

What is Known:

Ketamine is safely and efficaciously administered for children’s procedural sedation and analgesia by trained emergency paediatricians in the everyday practice outside the operating room in North America.

In the Italian setting, there are no data at all concerning ketamine’s usage by the emergency paediatricians for procedural sedation and pain control.

What is New:

In this study emerged that ketamine is poorly administered by Italian emergency paediatricians for procedural sedation and analgesia outside the operating room.

A great deal of educational effort should be made to widen ketamine based procedural sedation availability in Italian emergency departments by spreading specific training tracks and guidelines.


Ketamine Procedural sedation Emergency department Analgesia Children Child 



Blood pressure


Emergency department(s)


End-tidal CO2


Heart rate








Pain in Paediatric Emergency Room


Respiratory rate


Severe adverse event(s)


Italian Society of Emergency Physicians


Oxygen’s saturation



We would like to thank all the PIPER (Pain in Paediatric Emergency Room) group members who participated to the study:

T. Zangardi (Azienda Ospedaliera Universitaria, Padova); F. Marzona (Azienda Ospedaliera Universitaria, Udine); E. Barbi (Istituto Materno Infantile Burlo Garofolo, IRCCS, Trieste); D. Silvagni (Azienda Ospedaliera Universitaria Integrata, Verona); A. Arrighini (Azienda Ospedaliera Spedali Civili P.O. dei Bambini, Brescia); C. Scalfaro (Azienda Ospedaliera S. Carlo Borromeo, Milano); S. Fontanazza (Istituto Giannina Gaslini, IRCCS, Genova); L. Calistri (Azienda Ospedaliera Universitaria Meyer, Firenze); E. Fabiani (Azienda Ospedaliera Universitaria Salesi, Ancona); C. Tomasello (Ospedale Pediatrico Bambino Gesù, Roma); A. Chiaretti (Policlinico Agostino Gemelli, Roma); S. Barca (Azienda Ospedaliera di Como, Como); M. Bonora (Presidio Ospedaliero “Madonna delle Grazie”, Matera); M.R. Govoni (Azienda Ospedaliera Arcispedale Sant’Anna, Ferrara); R. Petrino (Ospedale Sant’Andrea, Vercelli); F. Borrometi (Azienda Ospedaliera Santobono Pausilipon, Napoli); R. Parrino (Presidio dell’ARNAS “Civico di Cristina–Benefratelli”, Palermo); A. Tornesello (Presidio Ospedaliero Vito Fazzi, Lecce); S. Faragò (Azienda Ospedaliera Puglieseciaccio, Catanzaro); F. Ferrero (Azienda Ospedaliera Universitaria Maggiore della Carità, Novara); A. Cella (Ospedale Guglielmo da Saliceto, Piacenza); P. Manfredi (Presidio Ospedaliero Vaio Fidenza, Parma); F. Midulla (Sapienza Università di Roma Deap Clinica Pediatrica, Roma); M. Taglietto (Città della Salute e della Scienza di Torino presidio OIRM, Torino); A. Tonetto (Presidio Ospedaliero San Donà di Piave, Venezia); S. Pusceddu (AUSL Romagna, Ravenna); M. Fantinato (Ospedale San Bortolo, Vicenza); C. Vezzoli (Spedali Cividi di Brescia, Brescia); S. Cherubini (Presidio Ospedaliero di Busto Arsizio, Varese); A. Sfacello (Ospedale Maggiore di Chieri, Torino); G. Molinaro (Azienda Ospedaliera dell’Alto Adige, Bolzano); L. Dell’Era (Clinica De Marchi Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano).

We would also like to thank the following revisors:

Steven M. Green, Piet L.J.M. Leroy, Mark G. Roback, Gary Andolfatto

Authors’ Contributions

Benedetta Bossini and Alberto Di Mascio wrote the first draft of this work, and no funding was received to write it. Each author (Alberto Di Mascio, Benedetta Bossini, Egidio Barbi, Franca Benini, Giorgio Cozzi) approves the submission of this version of the manuscript and takes full responsibility for it. Egidio Barbi, Franca Benini and Giorgio Cozzi reviewed the work.

Compliance with ethical statements

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors. The study did not involve any collection or analysis of personal data regarding human participants but only hospitals and policies, according to Italian law requirements for informed consent, and approval by Ethics Committee was not applied. In Italy ethical review is mandatory only for clinical trials on pharmaceutical products ( ) and for observational studies on use of drugs by human participants ( ).

Statement of informed consent

Each centres gave its informed consent to participate in the study.


  1. 1.
    Krauss B, Green SM (2006) Procedural sedation and analgesia in children. Lancet 367:766–780CrossRefPubMedGoogle Scholar
  2. 2.
    Green SM, Roback MG, Kennedy RM, Krauss B (2011) Clinical practice guideline for emergency department ketamine dissociative sedation. Ann Emerg Med 57(5):449–461CrossRefGoogle Scholar
  3. 3.
    Green SM, Roback MG, Krauss B, Brown L, McGlone RG, McKee M, Weiss M, Pitetti RD, Hostetler MA, Wathen JE et al (2009) Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children. Ann Emerg Med 54(2):158–168CrossRefGoogle Scholar
  4. 4.
    Grunwell JR, Travers C, McCracken CE, Scherrer PD, Stormorken AG, Chumpitazi CE, Roback MG, Stockwell JA, Kamat PP (2016) Procedural sedation outside of the operating room using ketamine in 22,645 children: a report from the pediatric sedation research consortium. Pediatr Crit Care Med 17(12):1109–1116CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Bhatt M, Johnson DW, Chan J, Taljaard M, Barrowman N, Farion KJ, Ali S, Beno S, Dixon A, McTimoney CM et al (2017) Risk factors for adverse events in emergency department procedural sedation for children. JAMA Pediatr 171(10):957–964CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Ellis DY, Husain HM, Saetta JP, Walker T (2004) Procedural sedation in paediatric minor procedures: a prospective audit on ketamine use in the emergency department. Emerg Med J 21:286–289CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Deasy C, Babl FE (2010) Intravenous vs intramuscular ketamine for pediatric procedural sedation by emergency medicine specialists: a review. Paediatr Anaesth 20(9):787–796CrossRefPubMedGoogle Scholar
  8. 8.
    Green SM, Rothrock SG, Lynch EL, Ho M, Harris T, Hestdalen R, Hopkins GA, Garrett W, Westcott K (1998) Intramuscular ketamine for pediatric sedation in the emergency department: safety profile in 1,022 cases. Ann Emerg Med 31(6):688–697CrossRefPubMedGoogle Scholar
  9. 9.
    Hartling L, Milne A, Foisy M, Lang ES, Sinclair D, Klassen TP, Evered L (2016) What works and what's safe in pediatric emergency procedural sedation: an overview of reviews. Acad Emerg Med 23(5):519–530CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Holloway VJ, Husain HM, Saetta JP, Gautam V (2000) Accident and emergency department led implementation of ketamine sedation in paediatric practice and parental response. J Accid Emerg Med 17:25–28CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Tsze DS, Steele DW, Machan JT, Akhlaghi F, Linakis JG (2012) Intranasal ketamine for procedural sedation in pediatric laceration repair. A preliminary report. Pediatr Emerg Care 28(8):767–770CrossRefPubMedGoogle Scholar
  12. 12.
    Roback MG, Carlson DW, Babl FE, Kennedy RM (2016) Update on pharmacological management of procedural sedation for children. Curr Opin Anaesthesiol 29(Suppl 1):S21–S35CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Alberto Di Mascio
    • 1
  • Benedetta Bossini
    • 1
    Email author
  • Egidio Barbi
    • 1
    • 2
  • Franca Benini
    • 3
  • Giorgio Cozzi
    • 2
  1. 1.Department of Medicine, Surgery and Health SciencesUniversity of TriesteTriesteItaly
  2. 2.Department of PediatricsInstitute for Maternal and Child Health–IRCCS ‘Burlo Garofolo’TriesteItaly
  3. 3.Paediatric Pain and Palliative Care Service, Department of Woman and Child HealthUniversity of PaduaPaduaItaly

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